Gracie Lane Day Hab, LLC

Primary specialty

Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X

License

CC03100514 Issued in MO

Legal business name

GRACIE LANE DAY HAB, LLC

Practice address

RR 81 Box 175
Koshkonong, MO 65692-8004

Phone

(417) 867-3397

Fax

(417) 867-3367

NPI assigned

Mar 18, 2016

Last updated

Mar 22, 2016By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Myrtle E Rigel, BSW

Title

Owner/Administrator

Phone

(417) 867-3397

Specialties & licenses 2

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1458259200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1458604800000",
    "number": "1881055812",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "RR 81 BOX 175",
            "city": "KOSHKONONG",
            "state": "MO",
            "postal_code": "656928004",
            "telephone_number": "417-867-3397"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "RR 81 BOX 175",
            "city": "KOSHKONONG",
            "state": "MO",
            "postal_code": "656928004",
            "telephone_number": "417-867-3397",
            "fax_number": "417-867-3367"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRACIE LANE DAY HAB, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-03-18",
        "last_updated": "2016-03-22",
        "status": "A",
        "authorized_official_last_name": "RIGEL",
        "authorized_official_first_name": "MYRTLE",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "OWNER/ADMINISTRATOR",
        "authorized_official_telephone_number": "417-867-3397",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "BSW"
    },
    "taxonomies": [
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "MO",
            "license": "CC03100514",
            "primary": true
        },
        {
            "code": "385H00000X",
            "taxonomy_group": "",
            "desc": "Respite Care",
            "state": "MO",
            "license": "CC03100514",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "856321104",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Koshkonong, MO
• Providers in Koshkonong, MO by specialty
• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 22, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.